50 year male patient presented shortness of breath and vomiting

General medicine 
Hi i am KALPAK MAWALE 3rd sem This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs


Cheif complaint -

A 50year old male ,labour by occupation came to OPD with chief complaints of  
shortness of breath since 5 days
Vomiting since 3 days

History of present illness-
Patient was asymptomatic 1 year back.
Then he Diagnosed with chronic kidney disease he is on conservative treatment.
SOB is insidious in onset, not present during rest and is more prevalent during night (PND). SOB is generally experienced after walking a short distance.The patient also complained that the breathlessness is increased by lying down suggesting orthopnea.
Vomiting is present since 5 days lmmediately after intake of food
No history of fever

History of past illness- 
The patient was known to be hypertensive since 1 year for which he is on regular medication
Also 1 year ago patient diagnosed with CKD

Personal history-

DIET: Mixed
APPETITE : Normal
BOWEL AND BLADDER: Regular
SLEEP: Adequate
ALLERGIC HISTORY: No known allergies
NO ADDICTION 

Family history -
Sister had hypertension

General examination-

The patient is conscious,coherent and Co-operative

The patient is moderately build and moderately nourished.

No pallor/No cyanosis/No clubbing of fingers/No lymphadenopathy/No icterus/No Oedema of feet

Vitals-

TEMPERATURE:98.6 degree F

PULSE RATE:102bpm

RESPIRATORY RATE:35/ min

BLOOD PRESSURE:180/100 mm Hg

SpO2:98%

GRBS:138 mg/dL

Systemic examination -

CVS:S1 S2 Heard,no murmurs 

RESPIRATORY SYSTEM:

No scars are seen on inspection
Shape of the chest:
Tracheal position:Centre
Bilateral Chest Movement 
Tracheal position is confirmed by palpitation
Dyspnea present 
Wheeze absent 
Breath sounds are Vesicular

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
no neck stiffness
no kerming's sign
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

Investigation -
Ultrasound, hemogram , serum iron, ECG,RFT, LFT, blood sugar random

Provisional diagnosis -
Chronic kidney disease
Chronic renal failure

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